Perspectives on Safety > Annual Perspective

Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.

Burnout in health care is a recognized issue that can diminish patient safety. This statement raises awareness of burnout in critical care clinicians, discusses organizational and individual factors associated with the problem, and offers strategies to prevent and address burnout. Recommended solutions include career counseling for new critical care clinicians and training for intensive care unit leaders to help them recognize problems that contribute to burnout and design interventions.

Newspaper/Magazine Article

Spotlighting the growing concern around alarm fatigue, this magazine article provides an overview of efforts to augment alarm management and offers recommendations for hospitals working to reduce unnecessary alarms, including eliciting insights from nursing staff about areas for improvement and performing direct observations in patient care settings to monitor frequency of alarms.

Journal Article > Study

This study examined inpatient suicides at Veterans Affairs hospitals and provided recommendations for mitigating risks. Hanging by using equipment present in psychiatric wards was the most common method of suicide.

Perspectives on Safety > Interview

Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.

Journal Article > Study

This survey study found that anesthetists' decisions to adhere to practice guidelines are affected by their beliefs about the consequences of not adhering, the influence of peers, and aspects of social approval.

Book/Report

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.

Cases & Commentaries

An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."

Cases & Commentaries

Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.

Cases & Commentaries

Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.